always or never - intermountainphysician · always or never mario gasparri, md division of thoracic...
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ALWAYS or NEVER
Mario Gasparri, MD Division of Thoracic Surgery SSM Health – St Mary's Hospital Madison, WI
Disclosures
DuPuy Synthes – Speaker
ALWAYS - NEVER
ALWAYS or NEVER Debate
Standard Strategy when Arguing Absolutes Use misdirection and lots of pictures Present small, anecdotal clinical experiences Somewhat sketchy logic Grossly overstate my side Won’t confuse the issues with actual facts
ALWAYS or NEVER Debate
Always or Never
Bronchoscopy Thoracoscopy Chest Tubes
Always Bronchoscopy
Easy
Always Bronchoscopy
Available
Always Bronchoscopy
Safe – Morbidity in this setting should be 0%
Safe
Always Bronchoscopy
Relatively Cheap
=
Always Bronchoscopy
Easy, Available, Safe, Cheap
Does “we CAN” = “we SHOULD”?
Why do we fix rib fx/flail? …SSRF decrease pain, shortened duration of
mechanical ventilation, decreased incidence of pneumonia, decreased likelihood of tracheostomy…
Consensus Statement - Injury 2017
Always Bronchoscopy
Pain / Impaired mechanics rib fx/flail
If we are in the OR They are already somewhere on this pathway Bronchoscopy/Secretion clearance can help at any point and
prevent this pathway to death
Poor Cough
Increased Secretions
Pneumonia Respiratory Failure
Death
Always Bronchoscopy
Bronchoscopy vs “Blind” Suctioning
60% of “blind” suctioning misses the secretions
Visual suctioning has greater volume of suction retrieved
Early bronchoscopy led to better outcomes
Always Bronchoscopy
Bronchoscopy is an Easy, Available, Safe, Cheap, and Effective solution to potentially Prevent Death
Standard of care in medicine is to Prevent Death
ALWAYS perform Bronchoscopy!!
Always Thoracoscopy
Rib fractures often have associated injuries 70% Hemothorax / 20% Lung Laceration Consensus Statement - Injury 2017
At least 5 diaphragm injuries Gasparri - Personal Experience
Routine Thoracoscopy Identification of these injuries Treatment of these injuries
Always Thoracoscopy
Hemothorax Drainage
Lung Laceration Repair
Improved outcomes when other injuries addressed
Always Thoracoscopy
Aids Incision Placement/Planning
The goals of the incision…are to (1) provide adequate exposure, (2) minimize morbidity…and (3) optimize cosmesis Consensus Statement - Injury 2017
Translation Do a good job with the smallest incision possible
Always Thoracoscopy
CalorieLab 2015
Always Thoracoscopy
Always Thoracoscopy
Internal visualization allows optimal placement of incision
Smaller, targeted incision are ideal
Always Thoracoscopy
Improve VATS skills Thoracoscopic SSRF offers several theoretical
advantages…wide visualization…small incision …elimination of scapular retraction…elimination of palpable plates…increased margin on posterior fx Consensus Statement - Injury 2017
Although currently limited by available technology, it is clearly the goal and what many are working towards
Routine use of VATS will • Increase surgeon skill set • Increase comfort level/efficiency of OR crew
Always Thoracoscopy
Improves outcomes Tx of hemothorax/lung laceration/other injuries
Decreases morbidity Allows smaller incisions
Increases surgeon skills/team efficiency Repetitive use
ALWAYS perform Thoracoscopy!!
Always Chest Tubes
If you agree with ALWAYS Thoracoscopy No further discussion Chest tube placed at the
end of the procedure Game over
Always Chest Tubes Reviewed rib fx patients
1/2009-6/2013 137 Rib Stabilization pts 274 Medically Managed pts At surgery, all pts had chest
tubes placed and the pleural space irrigated
Rib stabilization with chest tube • Decreased reintervention rate • Decreased empyema rate • Decreased readmission rates
Always Chest Tubes
Agree with ALWAYS thoracoscopy Chest tube placed at the end of the case
Landmark article Routine chest tube decrease reintervention,
empyema and readmission Remember the author
Tom says so!!
ALWAYS place Chest Tubes!!
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